RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00200
BRANCH OF SERVICE:  MARINE CORPS	BOARD DATE:  20150421
SEPARATION DATE:  20080115

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Mortarman) medically separated for a bilateral lower leg condition.  The CI’s condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued activity restrictions and eventually referred for a Medical Evaluation Board (MEB).  The MEB forwarded “other and unspecified disorders of soft tissue” and “other disorder of muscle, ligament, and fascia” to the Physical Evaluation Board (PEB).  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated “bilateral left greater than right chronic exertional compartment syndrome” as a Category I condition: unfit, rated 10% for each leg, for a combined disability of 20% for this condition.  The PEB also adjudicated “bilateral right greater than left anterior fascial herniations” as a Category II condition: contributing to the unfitting Category I condition.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Did not have a chronic condition prior to entering military.  USMXC discharged me for condition and VA did not recognize it”.  My VA paperwork states that I am 20% disability rating for my legs but I only receive 10% for my back which was diagnosed by an off base doctor in New Orleans.  I have not received any compensation for the disorder I was separated for.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

IPEB – Dated 20071105	VA* - (~2 Wks. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Left Greater Than Right Chronic Exertional Compartment Syndrome	8799-8723	10%	Compartment Syndrome With Muscle Herniations, Right
Lower Extremity	5326	0%	20080103-20080105	
Bilateral Left Greater Than Right Chronic Exertional Compartment Syndrome	8799-8723	10%	Compartment Syndrome With Muscle Herniations, Left Lower Extremity	5326	0%	20080103-20080105	
Bilateral Right Greater Than Left Anterior Fascial Herniations	Cat II	No VA Placement	
Other x 0 (Not In Scope)	Other x 1 (equals SC, NSC & deferred)	
RATING:  20%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20082220 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Bilateral Chronic Exertional Compartment Syndrome.  The narrative summary (NARSUM) noted the CI developed bilateral exertional compartment syndrome (ECS).  The CI developed leg pain, tightness, paresthesia, and foot drop after 5 minutes of activity that completely resolved after 15 minutes of rest, with muscle herniation.  Scant treatment notes in the service treatment record indicated that the CI developed symptoms before deployment, which gradually worsened.  He reported numbness of his leg from the mid-calf down while running, and pain, numbness, and tingling of his toes with more prolonged running.  At a sports medicine evaluation on 31 July 2007, the CI reported bilateral anterior and posterior leg pain, with calf muscle cramps precipitated by running and relieved by rest.  During the evaluation the CI exercised on a treadmill and after 5 minutes he developed symptoms with “foot slapping gait,” increased calf firmness, and prominence of the muscle hernias and the diagnosis was bilateral ECS.  According to the NARSUM the CI declined surgery and the MEB examiner indicated this was reasonable because the symptoms only affected the CI when he was performing military activities and the CI’s perspective was that he would not be required to do those activities as a civilian.

At the MEB examination on 21 September 2007, 4 months prior to separation, the CI reported symptoms with fast paced walking or running, but no symptoms at rest.  The MEB physical exam noted good pulses, sensation and strength of the lower legs.  The leg compartments were supple and the right leg had three muscle herniations.  Resting lower leg muscle compartment pressures were elevated indicative of ECS.  There were no X-ray abnormalities of the tibia or fibula.

At the VA Compensation and Pension examination on 3 January 2008, 2 weeks prior to separation, the CI reported calf pain when walking fast or running.  He reported anterior muscle hernias that were painful.  The exam noted no muscle scarring.  There was anterior muscle herniation bilaterally.  Muscle strength of the ankles was graded 4/5.  Muscle function was noted to be abnormal in terms of “comfort, endurance, and strength sufficient to perform activities of daily living.”

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated bilateral ECS and provided 10% ratings each for the left and right, coded 8799-8723 (analogous to incomplete paralysis of the deep peroneal nerve), combined 20% rating.  The VA rated the left and right legs each 0%, coded 5326 (muscle hernia, extensive).  The Board first considered the coding of the bilateral ECS.  The Board noted that the rating criteria of 8723 are subjective with 0% for mild and 10% for moderate deep peroneal neuralgia.  The evidence supports that the CI experienced symptoms referable to the deep peroneal nerve of numbness of the anterior lower leg, and pain, numbness, and tingling of the toes, and weakness of dorsiflexion with activity.  Members agreed that both the left and right ECS met the 10% rating coded as 8799-8723 and noted that IAW VASRD §4.124 when coding analogously to neuralgia, maximum rating will be for moderate incomplete paralysis.  The Board alternatively considered rating IAW §4.73 (Muscle injuries) with an accepted analogous code for anterior compartment syndrome of 5399-5312 (analogous to muscle Group XII injury).  The evidence supports muscle weakness during activity which resulted in a “foot slapping gait,” likely due to tibilais anterior muscle weakness (muscle Group XII).  Members noted that rating criteria of 5312 are subjective and similar to the 8723 criteria with a 0% rating for slight, 10% for moderate, and 20% for moderately severe muscle injury.  Member consensus was that the ECS condition exceeded the criteria for slight muscle injury due to the presence of cardinal symptoms of muscle injury of reproducible muscle pain, swelling and weakness that limited activity (fatigue-pain), and that the ECS condition was best described as moderate and not moderately severe based upon the complete absence of leg symptoms at rest or with mild activity.  Therefore, the Board agreed that both the right and left ECS conditions met a 10% rating with either coding approach.  The Board reviewed the VA coding choice of 5326 but found that the highest rating available was 10% for extensive muscle herniations; thus, no possible higher combined rating than that conferred by the PEB could be achieved.  The Board thus agreed that the evidence in record did not support a higher evaluation for either the right or left ECS with any applicable code.  The Board noted that the PEB also adjudicated bilateral right greater than left anterior fascial herniations as a Category II condition(s).  A Category II condition is a condition that contributes to the unfitting condition but is not separately ratable.  In this case the muscle herniations through the fascial tissue are part of the ECS conditions and contribute to the overall disability, but cannot be rated separately IAW §4.14 (Avoidance of pyramiding).  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right and left ECS conditions.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matters of the right and left ECS conditions and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131229 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 5 Aug 15

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC